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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1115063-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA1) displayed frustration, a staff person (SP) pushed VA1 onto a couch, pinned his/her arms down and possibly left bruises and that the SP used his/her body to barricade VA1 in a corner. It was also reported that when another vulnerable adult (VA2) displayed self-injurious behavior (SIB), the SP grabbed VA2’s arms. Date of Incident(s): Prior to June 2, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 26, 2023, from documentation at the facility and through eight interviews conducted with the SP, VA1’s guardian (G1), VA2’s guardian (G2), four facility staff persons (P1-P4) and a facility management staff person (P5). VA1 and VA2, who were non-verbal, were not able to be interviewed as part of the investigation due their respective diagnoses. VA1’s support plan showed that s/he enjoyed participating in leisure activities, recreation, and “socialization.” The plan showed that VA1 had a severe development disability and engaged in verbal/physical aggression toward others. When that happened, staff persons were trained to provide verbal redirection to VA1. VA2’s support plan showed that s/he enjoyed accessing the community and was “easy going.” The plan showed that VA2 also had a severe developmental disability. The plan stated that when VA2 engaged in SIB, staff persons were to “determine what is wrong by process of elimination.” P5, and information from the facility’s Internal Investigation, provided the following information: · On May 16, 2023, P1 talked to P5 because P1 “heard” from P2 that the SP “pinned” VA1 in a corner when VA1 had a “behavior” and that the SP used his/her legs as a “cage.” P5 was “under the impression” that this happened a while ago “with the previous provider.” P1 also told P5 that while VA2 engaged in SIB on an unspecified date, the SP “held” VA2’s arms “down.” P5 believed that the SP had a “dominating presence” and that this had been previously discussed with the SP. P5 had not witnessed any interactions between the SP and VA1 or VA2 that were concerning to P5. · When P5 interviewed P1, P1 remembered an incident that happened on May 23, 2023, in which VA1 was trying to leave the facility while the SP was cooking. When VA1 did not like the show that was on the television, VA1 turned the television off and when that happened, the SP said, “Nope, not today,” and while the VA sat on the couch, the SP “held” him/her down for 45 seconds. When that happened, P1 took a picture because P1 “found it alarming” because VA1 “looked like [s/he] was in shock.” P1 told P5 that the SP was “very stern” and would say things like, “I don’t want to be here.” P1 also stated that when VA2 engaged in SIB, staff persons were instructed to “block” the “blows,” but that the SP “held” VA2’s arms. · When P5 talked to P2, P2 said that the SP was “rougher” than other staff persons when the SP worked with VA1. P2 also stated that although the SP told others to “walk away” when the VAs engaged in behavioral incidents, the SP “never” walked away. P2 was also concerned that the SP used his/her “size” as a means to “intimidate people.” · P1 told P5 about a recent incident in which VA1 moved to a corner and that the SP used his/her body, but not his/her hands, as a means to “prevent” VA1 from moving out of the corner (for an undetermined amount of time) until VA1 calmed down. The SP told P5 that VA1 had the ability to move away if s/he wanted to, but VA1 did not move away until s/he was calm and that the SP did not hold VA1. · When P5 talked to another staff person (P6), P6 stated that although s/he had not observed the SP to be “forceful,” P6 noted that the SP “tends to use intimidation versus communication when there is a problem.” P6 also stated that the SP’s “attitude has progressively gotten worse” and that the SP “says out loud that [s/he] doesn’t want to be here.” P6 stated that although s/he saw bruising on VA2’s left arm, VA2 “bruises easily” and P6 did not know how VA2 got the bruises. · When P5 talked to the SP, the SP stated that VA1 “likes to be pushed down” onto the couch and that VA2 would “stand right back up” and “want you to do it again.” The SP denied causing bruising to any of the clients and denied yelling or raising his/her voice. The SP remembered the incident in which VA1 backed into a corner and when that happened, the SP placed his/her foot by VA1’s foot to “wait [him/her] out,” until VA1 calmed. · During the investigation, P5 obtained a photograph, taken by P1 on May 22, 2023, which showed VA1 sitting on a couch and the SP “leaning” over VA1 and the SP’s “arms are slightly bent at the elbow, but otherwise extended down toward [VA1’s] chest. It is difficult to discern much more.” P5 also received a photograph, taken by G1 on May 23, 2023, which showed two bruises “about the size of a pencil eraser” and three to four “smaller bruises” near VA1’s left armpit. P1 and P2 provided information to this investigator that was similar to the information provided in the facility’s Internal Investigation. The SP provided information that was similar to the information provided in the facility’s Internal Investigation, but added the following additional information during an interview with this investigator: · When VA1 engaged in behavioral concerns, the SP would “move out of the way or block” VA1, which meant that the SP used his/her hand to prevent VA1 from “biting or scratching.” The SP denied pushing or holding VA1 on the couch. In addition, the SP denied barricading VA1 in a corner. The SP denied causing bruises on VA1. · The SP denied grabbing VA2’s arms and causing bruising on VA2. · When the SP was asked to describe his/her tone of voice, the SP stated that his/her voice was “regular” and “standard.” P3 and P4 each stated that s/he had not observed any interactions between staff persons and the VAs that was concerning and that s/he had not observed any bruising on the VAs. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that consumers have the right to be treated with courtesy and respect. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and VA1 and VA2’s specific care plans prior to June 26, 2023. Conclusion: Information showed that P1 and P2 told P5 about “concerns” they had about the SP’s interactions with VA1 and VA2. P1 stated that the SP “held” VA1 down on a couch and took a photo. P5 saw the photo and it showed VA1 sitting on the couch with the SP “leaning” over VA1. P5 stated that it was “difficult to discern much more.” The next day, the VA had some “smaller” bruises near his/her armpit. The SP told P5 that sometimes VA1 “liked” to be “pushed” to the couch and would stand and wanted to do it again. The SP denied holding VA1 on the couch and denied causing bruises. P1 stated that one occasion, VA1 was in a corner and the SP “prevented” VA1 from leaving with his/her body. The SP told P5 that s/he was waiting for VA1 to calm and that VA1 could move if s/he wanted to. The SP did not use his/her hands to restrict VA1. P2 stated that when VA2 engaged in SIB, the SP “held” VA2’s arms. Staff persons were supposed to “block” VA2. The SP denied holding VA2’s arms. P1 stated that the SP was “very stern,” and P2 and P6 each stated that the SP could be “intimidating.” The SP being “intimidating” was behavior that was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that the SP denied holding VA1 or VA2, that when the SP stood near VA1 in the corner, the SP did not restrict VA1’s movement and was waiting for VA1 to calm, that the photo P1 took of the SP only showed the SP leaning over VA1 who was sitting on the couch, and that it was not determined what caused VA1’s or VA2’s bruises, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic in nature or whether the SP’s actions could be reasonable expected to cause pain or emotional distress. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an Internal Investigation and determined that policies and procedures were adequate, followed, and that additional training was needed. In addition, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: A Correction Order was not issued for the violation outlined in this report because the facility took immediate action.
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